The Effect of Self-Care Training on Cognitive Distortions in Volunteer Instructors of Sexual Education to Children

ORIGINAL ARTICLE Background: Unfamiliarity with the process of self-care training and sexual education can make sexual education volunteer instructors stressful and create incorrect attitudes for them. Therefore, the objective of this study was to investigate the effectiveness of self-care training on cognitive distortions in volunteer instructors of sexual education to children. Methods: This quasi-experimental study was conducted using a pretestposttest and control group design. The statistical population included all individuals who volunteered to take part in the courses of instructor training on sexual self-care skills and sexual education. These courses were held by the Civil Society Forum for Child Rights in 2018. Among the volunteers, 30 people were selected by purposive sampling and were randomly replaced into the interventional (15 individuals) and control (15 individuals) groups. The questionnaire of cognitive distortions was used to collect the required information and the collected data were analyzed via ANCONA by SPSS23. Results: The results showed that self-care training was effective on cognitive distortions of volunteer instructors of sexual education to children (P < 0.001). In other words, this training decreased cognitive distortions of the volunteers. The effect of this training on cognitive


Introduction
The world is currently faced with social crises besides the environmental, economic, and poverty crisis; the threat of war and insecurity is also one of the most painful challenges that causes social, cultural, and psychological disadvantages of child abuse. The effects and outcomes of child abuse can be examined from two perspectives: short-term and long-term effects. In the sense that some of these effects occur only in the children and cause problems for them, child abuse long-term effects affect a person's future individually and socially. Accordingly, physical and emotional complications, such as severe fears, feelings of guilt, anxiety, depression, insomnia, decreased self-esteem, home escape, suicide, and conversion of a child into an abnormal and antisocial personality are considered as the consequences of child abuse. 1,2 Adults have the duty to protect these innocent angels and provide them with a good educational, physical, sexual, cognitive, spiritual, moral, and social background. Nowadays, it seems that education and all educational organizations are responsible for stepping in the path of innovation to revise the theories, methods, and educational resources appropriate to the needs of children and adolescents. In addition, they emphasize the necessity of having a special place for educating and training the trainers and the educational staff. 3 Given the increasing number of social harms that affect the future of children, sexual education training with a focus on preventing sexual harassment seems to be very important. 4 Child sexual education should be a primary concern for parents; so, sexuality and self-care should be transmitted to the child at the right time in accordance with their child's sexual and ageappropriate circumstances. Parental negligence and not providing the children with sexual education increase the possibility of sexual exploitation. Families should present self-care education in a simple manner to children; they should be aware of their private organs that should not be touched by anyone. However, these simple tutorials are not given to children because talking about sexual issues is a taboo in families, especially in more societies. 5 In addition to parents, other educators in selfcare education and child-rearing can teach children self-care in educational programs. These people have the responsibility to share the sexual issues and self-care affairs associated with them and educate children about self-care and sexuality that can lead to safe interaction of children. At the outset, volunteers of training sexual education to children are often skeptic about the effectiveness of this education; so, they develop ineffective attitudes and cognitive distortions. Cognitive distortions are thoughts that inhibit the person to understand the issues properly. In fact, patterns of thought exist that reinforce negative thoughts and feelings, which are usually interfered by the individual's perception of the matters and do not allow him/her to have a reasonable understanding. 6 Individuals' way of thinking depends on how they feel and this distortion of thoughts can lead to negative emotions. These thoughts negatively affect one's attitude toward the future and the world and their perseverance leads to anxiety, depression, and mental illness. 7 Cognitive distortions, if occur alternatively and continuously, lead to discomfort and psychological disorders in people. 8 One way that affects people's psychological and emotional trauma is self-care training that has been used to reduce the cognitive impairment of pediatric nursing students. Previous studies conducted by Samawati, 9 Aghakhani, et al. 10 Shams, Moradi, Zaker, 11 Chen, Thornton et al., 12 Miller, et al., 13  Self-care is the deliberate and targeted learning measures and behaviors performed to maintain and improve their health. In other words, self-care is a conscious action adopted by an individual to meet the self-care needs. 16 Self-care needs are divided into three groups of general needs, deviations from health, and evolution . 17 The evolutionary self-care needs are designed based on the individuals' developmental stages, their living environment, and the environment impact. Such needs are related to the changes in life and the stages of life cycle. 18 Given the negative role of cognitive distortions in individual, social, and occupational performance of individuals, it is necessary to carry out studies on the reduction of cognitive distortion among children undergoing sexual education. In the case of effectiveness, reducing cognitive distortion can improve the performance of an individual in educational and occupational activities. Moreover, due to the lack of research over the effectiveness of self-care education on cognitive distortion in volunteers of instructing sexual education to children, the necessity of this research is more prominent. Based on these conditions, the researchers tried to study the impact of this training on the cognitive distortion of sexual education volunteers. So, the research hypothesis was: -The effectiveness of self-care training has an impact on the cognitive distortion of children sexual education volunteers.

Methods
The present study was based on the method of semi-experimental research with pretest posttest and control group design. Independent variable was the self-care education and the dependent variable was cognitive distortion of the children's sexual education volunteers. The statistical population of this study included all volunteers who participated in the training course on sexual self-care skills and sexual education implemented by Civil Society Forum for Child Rights in 2018. In this research, a purposive random sampling method was used to select the volunteers interested in training sexual abuse prevention skills to children. The participants were given a cognitive distortion questionnaire and their scores were calculated. Later, 30 participants who obtained the highest scores were selected and randomly assigned into the interventional (N = 15) and control (N = 15) groups. Cohen's method was used, the desired effect size of 0.50 and the test power of 0.65 were obtained and the required sample size for both groups was calculated as 14. 19 However, to ensure about the sample size 15 15 members were selected for each group. The inclusion criteria were being volunteer for training sexual abuse prevention skills to children, having no acute or chronic physical illnesses, having a minimum degree of education, and having satisfaction to participate in the study. Moreover, the criteria for leaving the research were more than two sessions of absenteeism, lack of cooperation and nonfulfillment of the specified assignments in the classroom, unwillingness to continue the process of research, and occurrence of unplanned incidents that may disrupt one's attendance in the training sessions. The interventional group received the educational intervention (Self-care training based on sexual abuse prevention skills) in 8 sessions of 90 minutes during two months. This is while people in the control group did not receive any intervention during the study process. It should be noted that in order to observe the research ethics, the individuals' consent to participate in the intervention program was obtained and the participants were informed about all stages of the intervention. The control group members were also ensured that they would receive the educational contents after completion of the research process.

Cognitive Distortions Scale (CDS)
To measure cognitive distortions, a 20-point scale of cognitive distortion was developed by Abdollahzadeh and Salar in 2009. 20 This questionnaire was used to measure the participants' awareness of cognitive distortions. The scoring questionnaire consists of 20 items, which should be answered on a 5-point scale: totally agree (1 score), agree, do not comment, disagree, and completely disagree (5 scores). The subscales of this questionnaire include Polarized thinking, Overgeneralization, Filtering, Disqualifying the positive, Jumping to conclusions, Exaggeration and Minimization, Emotional reasoning, Should statement, Labeling, and Personalization. The total attainable scores in this questionnaire range from 20 to 100. Higher total scores show more positive thinking. Of course, the first question is scored reversely. Reliability of this questionnaire was confirmed by internal consistency and Test-retest (after two weeks) by the Cronbach's alpha of 0.69 and 0.95, respectively. 20 To carry out the research, the necessary coordination was made with the Civil Society Forum for Child Rights' authorities in Tehran. Later, the researchers referred to this society, selected the participants, asked them to sign informed consent forms, and divided them into the interventional and control groups. Furthermore, participants of the intervention group were informed about all stages of the intervention and the control group members were ensured that they would receive the same educations after completion of the research process. Both groups were also ensured about confidentiality of information and the fact that they were not required to enter their names.
In this research, descriptive and inferential statistics were used to analyze the data. At the level of descriptive statistics, the mean and standard deviation and at the level of inferential statistics, Shapiro-Wilk test were applied to assess the normal distribution of variables. Levine test was also used to examine the equation of variances and ANCOVA was run to study the research hypothesis. Statistical analysis was performed using IBM-SPSS-23 software.

Results
Findings of the demographic data showed that participants of the research were in the age range of 27 to 38 years, while the participants were most frequently within the age range of 31 to 34 years (32%). The highest frequency was related to the bachelor's degree in education (83.33%). The descriptive findings of the research are represented in Table 2: Before presenting outcomes of the covariance test, the tests' assumptions were evaluated. Accordingly, the results of the Shapiro Wilk test indicated that the data samples were normally distributed with regard to the cognitive distortion variable in the pre-test and post-test (p > 0.05). The homogeneity of variance was also determined by Levin's, which was not significant. This indicated that the homogeneity of variances was presumed in the cognitive distortion variable (p > 0.05). On the other hand, the results of independent t-test showed that the difference between the pre-test scores of the interventional and control groups in the dependent variable (cognitive distortion) was not significant (p > 0.05).
Regarding the results of Table 3, presentation of the independent variables (Self-care education) could lead to a significant difference in mean scores of the dependent variables (cognitive distortion of volunteers for training child sexuality education) in the post-test at the error level of 0.05. Therefore, it can be said that the cognitive distortion variable scores changed significantly. As a result of self-care education, the mean of cognitive distortion component in the experimental group decreased significantly. Furthermore, considering the effect size of this variable, it can be said that 0.78 variations of the cognitive distortion variables of volunteers for teaching children's sexual education are eliminated by self-care education. SBRH Members' acquaintance with each other, a review of the structure of the sessions, relevant rules and regulations and the method of implementation, the definition of selfcare skills, the study of the results of researches and the correct and incorrect assumptions about self-care skills 2 Self-awareness is the first step for self-care, including awareness of weaknesses and strengths to give us the power to make changes. Focusing on the value.
How to live purposefully, understand what is important.
The stages of success are in combining emotions, reactions, personality, and behavior that makes our future. 3 Understanding our emotional and psychological needs that includes the emotion that we have about ourselves and our ability to manage feelings and sometimes confront them, Awareness of mental health or, more importantly, depression, anxiety.
Satisfaction, self-confidence, trust and intimacy, desire for life and happiness, the ability to cope with stress and adapt to changes. Planning for leisure time 4 Reducing worries, teaching techniques to stop worries. Teaching the principles of positive and optimistic thinking, teaching techniques for reducing expectations.
In this principle, people are taught to spend more time on pleasurable work. Also, people should be able to put aside their negative thoughts because negative thoughts reduce the happiness and increase their inconvenience.

5
Teaching technique for the development of positive thinking, optimism and life in the present.
Teaching that happiness is always present here and in the present, not elsewhere or at another time. Happy people enjoy more than unpleasant people. Because they are not busy with their bitter events and do not miss the day that they did not come.

6
Nurturing a healthy personality and teaching the principles of social character creation The expression of the basic principles of a healthy and social personality, the explanation of traits such as natural, spontaneous, comfortable, reliable, and unaffected.

7
The importance of self-care focused on preventing sexual abuse of children Expression of statistical data about sexual abuse of children, characteristics of children abusers, preventive strategies and post-accident intervention 8 Teaching and practicing the child self-care package of the society of children rights support.
Run post-tests, summarize and review the past sessions

Discussion
This study aim was to investigate the effectiveness of self-care training on cognitive distortions in volunteers of children's education about sexual self-care skills. The results showed that self-care training was effective on cognitive distortions of the volunteer instructors of sexual education to children. This training could reduce cognitive distortions in volunteer trainers. The results of this study were confirmed in other studies. [9][10][11][12][13][14] As the results of these researchers indicate, this training improved psychological, physiological, and emotional components such as emotional regulation, early maladaptive schemas, ineffective attitudes, and maladaptive attitudes in different individuals. In the present elucidation, it can be said that people with a higher cognitive distortion have increased anxiety, anger, psychological stress, and insecurity in their interpersonal relationships; so, their social function decreases. People with cognitive distortion have lower social function and lower quality of life than healthy people. 7,6 This finding can be explained by the fact that negative and harmful characteristics of this trait can be controlled through interventional training. Self-care skills training can have a significant effect on personal competence, tolerance of negative emotions, inhibition of health indicators, and reduction of psychological vulnerability by influencing the cognitive distortion. Therefore, it can be said that psychological vulnerability increased cognitive distortion and reduced hope and helplessness. In this regard, depression and anxiety are considered as the consequences of lack of self-care skills. This pathological preparation provides the grounds for increasing cognitive and negative distortions. In other words, an increase in cognitive distortions against events in a person's life can be accompanied by a feeling of psychological pressure. Accordingly, reduction in the amount of cognitive distortion among the trained people is justified in comparison with the control group who did not receive training.
In another description, it can be argued that people with more power of self-care education in coping with life's problems and stresses are less exposed to psychological and emotional disturbances and enjoy a higher level of mental health and well-being. 13 People with positive and hopeful cognitive processes look at issues in a creative and flexible way, away from intellectual errors; they plan to solve problems, they do not hesitate to ask for help from others and resources. They are perfect for coping with problems, which leads them to higher mental health and psychological well-being and decreases their cognitive impairment. Additionally, self-care skills can be considered as facilitative educational skills and can be effective by enhancing one's cognitive and psychological factors. Self-care skills also help the individuals to become aware of and access their powerful internal resources. 12 Accordingly, self-care education helps people to take advantage of their potential and use these forces effectively. The use of internal resources also improves the personal and social performance of individuals and reduces their cognitive and inefficient distortions.
Considering the study limitations, the limited research scope for volunteers in the field of sexual education coaching in Tehran and lack of a followup period can be mentioned. Therefore, in order to SBRH. Volume 3, Issue 2, Nov2019; 402-409 408 increase the power of generalizability of the results, similar research should be carried out in other provinces and regions with different cultures, about other injuries, and with follow-up phases.

Conclusion
Regarding the effectiveness of self-care training on cognitive distortions in volunteers of instructing sexual self-care to children, self-care education courses should be conducted as an effective way to reduce the cognitive distortions of children coaching volunteers to protect from the children's rights.